Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: A systematic review and meta-analysis

Oncologic investigation of the interval from stent placement to surgery in patients with obstructive colorectal cancer

PURPOSE

Self-expandable metallic stent (SEMS) placement is widely used as a bridge to surgery (BTS) procedure for obstructive colorectal cancer. However, evidence regarding the optimal interval between SEMS placement and elective surgery is lacking.

METHODS

We retrospectively collected data from patients with BTS between January 2013 and October 2021. Inverse probability treatment-weighted propensity score analyses were used to compare short- and long-term outcomes between the short-interval (SI) and long-interval (LI) groups, using a cutoff of 20 days.

RESULTS

In total, 138 patients were enrolled in this study (SI group, n = 63; LI group, n = 75). In the matched cohort, the patients' backgrounds were well balanced. The incidence of Clavien-Dindo grade ≥ II postoperative complications was not significantly different between the SI and LI groups (19.0% vs. 14.0%, P = 0.47). There were no significant differences between the SI and LI groups in the 3-year recurrence-free survival (68.0% vs. 76.4%, P = 0.73) or 3-year overall survival rates (86.0% vs. 90.6%, P = 0.72).

CONCLUSIONS

A longer interval did not deteriorate the oncological outcomes. Individual perioperative management with an appropriate interval to improve the patient's condition is required to ensure safe surgery.

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies

BACKGROUND

The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.

OBJECTIVE

To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.

DATA SOURCES

A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.

STUDY SELECTION

Randomized controlled trials and propensity score-matched studies.

INTERVENTIONS

Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.

MAIN OUTCOME MEASURES

Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.

RESULTS

Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.

LIMITATIONS

There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.

CONCLUSIONS

This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Colon stenting as a bridge to surgery in obstructive colorectal cancer management

Colonic stent placement is a commonly used bridging strategy for surgery in patients with obstructive colorectal cancer. The procedure involves the placement of a self-expandable metallic stent (SEMS) across the obstructive lesion to restore intestinal patency and alleviate the symptoms of obstruction. By allowing patients to receive surgery in a planned and staged manner with time for preoperative optimization and bowel preparation, stent placement may reduce the need for emergency surgery, which is associated with higher complication rates and poorer outcomes. This review focuses on the role of colon stenting as a bridge to surgery in the management of obstructive colorectal cancer. SEMS as a bridge to surgery for left-sided colon cancer has been demonstrated to be particularly useful; however, further research is needed for its application in cases of right-sided colon cancer. Colon stent placement also has limitations and potential complications including stent migration, re-obstruction, and perforation. However, the timing of curative surgery after SEMS placement remains inconclusive. Considering the literature to date, performing surgery at an interval of approximately 2 weeks is considered appropriate. Therefore, colonic stent placement may be an effective strategy as a bridge to surgery in patients with obstructive colorectal cancer.

The management of complicated colorectal cancer in older patients in a global perspective after COVID-19: the CO-OLDER WSES project

BACKGROUND

Colorectal (CRC) cancer is becoming a disease of the elderly. Ageing is the most significant risk factor for presenting CRC. Early diagnosis of CRC and management is the best way in achieving good outcomes and longer survival but patients aged ≥75 years are usually not screened for CRC. This group of patients is often required to be managed when they are symptomatic in the emergency setting with high morbidity and mortality rates. Our main aim is to provide clinical data about the management of elderly patients presenting complicated colorectal cancer who required emergency surgical management to improve their care.

METHODS

The management of complicated COlorectal cancer in OLDER patients (CO-OLDER; ClinicalTrials.gov ID: NCT05788224; evaluated by the local ethical committee CPP EST III-France with the national number 2023-A01094-41) in the emergency setting project provides carrying out an observational multicenter international cohort study aimed to collect data about patients aged ≥75 years to assess modifiable risk factors for negative outcomes and mortality correlated to the emergency surgical management of this group of patients at risk admitted with a complicated (obstructed and perforated) CRC. The CO-OLDER protocol was approved by Institutional Review Board and released. Each CO-OLDER collaborator is asked to enroll ≥25 patients over a study period from 1st January 2018 to 30th October 2023. Data will be analyzed comparing two periods of study: before and after the COVID-19 pandemic. A sample size of 240 prospectively enrolled patients with obstructed colorectal cancer in a 5-month period was calculated. The secured database for entering anonymized data will be available for the period necessary to achieve the highest possible participation.

RESULTS

One hundred eighty hospitals asked to be a CO-OLDER collaborator, with 36 potentially involved countries over the world.

CONCLUSIONS

The CO-OLDER project aims to improve the management of elderly people presenting with a complicated colorectal cancer in the emergency setting. Our observational global study can provide valuable data on the effectiveness of different management strategies in improving primary assessment, management and outcomes for elderly patients with obstructed or perforated colorectal cancer in the emergency setting, guiding clinical decision-making. This information can help healthcare providers make informed decisions about the best course of action for these patients.

Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes

BACKGROUND

Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES).

METHODS

This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes.

RESULTS

Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed. Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence. Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55). Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence.

CONCLUSIONS

There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.

Transcatheter arterial perfusion chemotherapy combined with lipiodol chemoembolization for advanced colorectal cancer complicated by obstruction

Background

Obstruction is a common complication of advanced colorectal cancer. This study was aimed at investigating the safety, efficacy, and feasibility of transcatheter arterial perfusion chemotherapy combined with lipiodol chemoembolization for treating advanced colorectal cancer complicated by obstruction.

Patients and methods

This retrospective analysis was conducted using clinical data of patients with advanced colorectal cancer who received arterial infusion chemotherapy combined with lipiodol chemoembolization treatment at our center. Treatment efficacy was evaluated in terms of obstruction-free survival and overall survival, and treatment complications were monitored.

Results

Fifty-four patients with colorectal cancer complicated by obstruction were included. All patients successfully underwent transcatheter arterial infusion combined with lipiodol chemoembolization treatment. The average lipiodol dose administered was 2.62 ± 1.45 ml (0.5-5.5 ml). No serious complications such as perforation or tumor dissemination occurred. The clinical success rate was 83.3% (45/54). One month after treatment, the objective response rate (ORR) and disease control rate (DCR) were 66.67% and 88.9%, respectively. The median obstruction-free survival was 5.0 months. No serious adverse events occurred. As of the last follow-up, 6 patients survived, 44 died, and 4 were lost to follow-up.

Conclusion

Our findings revealed that transcatheter arterial infusion chemotherapy combined with lipiodol chemoembolization is safe and effective for treating advanced colorectal cancer complicated by obstruction. It may serve as a new treatment strategy for patients with advanced colorectal cancer complicated by obstruction.

Colonic Resection, Stoma, or Self-expanding Metal Stents for Obstructive Left Colon Cancer: the CROSCO-1 study protocol

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes.

METHODS

CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC.

RESULTS

The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

CONCLUSIONS

The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

Colonic stenting in acute malignant large bowel obstruction: audit of efficacy and safety in a Singapore tertiary referral centre

Introduction

Acute malignant large bowel obstruction (MBO) occurs in 8%-15% of colorectal cancer patients. Self-expandable metal stents (SEMS) have progressed from a palliative modality to use as bridge to surgery (BTS). We aimed to assess the safety and efficacy of SEMS for MBO in our institution.

Methods

The data of patients undergoing SEMS insertion for MBO were reviewed. Technical success was defined as successful SEMS deployment across tumour without complications. Clinical success was defined as colonic decompression without requiring further surgical intervention. Rates of complications, median time to surgery, types of surgery and rates of recurrence were studied.

Results

Seventy-nine patients underwent emergent SEMS placement from September 2013 to February 2020. Their mean age was 68.8 ± 13.8 years and 43 (54%) patients were male. Mean tumour length was 4.2 cm ± 2.2 cm; 89.9% of malignant strictures were located distal to the splenic flexure. Technical and clinical success was 94.9% and 98.7%, respectively. Perforation occurred in 5.1% of patients, with none having stent migration or bleeding. Fifty (63.3%) patients underwent SEMS insertion as BTS. Median time to surgery was 20 (range 6-57) days. Most (82%) patients underwent minimally invasive surgery. Primary anastomosis rate was 98%. Thirty-nine patients had follow-up beyond 1-year posttreatment (median 34 months). Local recurrence and distant metastasis were observed in 4 (10.3%) and 5 (12.8%) patients, respectively.

Conclusion

Insertion of SEMS for acute MBO has high success rates and a good safety profile. Most patients in this audit underwent minimally invasive surgery and primary anastomosis after successful BTS.

Which treatment strategy is optimal for acute left-sided malignant colonic obstruction? A Bayesian meta-analysis

PURPOSE

This study aimed to determine the best treatment for acute left-sided malignant colonic obstruction (ALMCO) among emergency surgery (ES), self-expanding metallic stent (SEMS), transanal drainage tube (TD), and decompressive stoma (DS).

METHOD

Articles that compared two or more treatments of ALMCO were searched from PubMed, Cochrane Library, and Embase. Network meta-analyses were performed to calculate the outcomes of primary anastomosis, stoma creation, morbidity, mortality, and 5-year survival.

RESULTS

Fifty-one articles met inclusion criteria. TD was the optimal treatment in performing primary anastomosis [probability of ranking first (Pro-1) 0.96], while ES was the worst [probability of ranking fourth (Pro-4) 0.99]. More permanent stoma was formed in ES and TD groups than in SEMS and DS groups [OR (95%CI): TD vs SEMS: 4.12 (1.89, 9.45); TD vs DS: 3.39 (1.46, 8.75); ES vs DS: 2.55 (1.73, 4.17); SEMS vs ES: 0.33 (0.24, 0.42)]. More morbidity occurred in ES group than in SEMS group [OR (95%CI): ES vs SEMS: 1.44 (1.14, 1.82)]. Besides, SEMS was ranked first in avoiding infection (Pro-4 0.95). For in-hospital mortality, ES was ranked first (Pro-1 0.93). TD was ranked first in recurrence (Pro-1 0.97) and metastasis (Pro-1 0.98). There was no discrepancy in 5-year overall and disease-free survival among all strategies.

CONCLUSION

SEMS as a bridge to surgery reduces stoma formation, and morbidity especially the infection rate with relatively great oncological outcomes. Therefore, SEMS should be recommended first for ALMCO in the medical center with experience and conditions.

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis

BACKGROUND

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated.

OBJECTIVE

The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer.

DATA SOURCE

A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included.

INTERVENTION

Stent or emergency resection in right-sided obstructive colon cancer.

MAIN OUTCOME MEASURES

Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent.

RESULTS

A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016).

LIMITATION

No randomized controlled trials are available.

CONCLUSION

Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

Laparoscopic Versus Open Pre-Treatment Loop Colostomy for Fecal Diversion in Rectal Cancer Patients: Is Laparoscopic Colostomy Better?

Diversion colostomy plays a crucial role in the management of carcinoma rectum in low- and middle-income countries as significant number of patients present with partial intestinal obstruction. The aim of this study was to compare laparoscopic and open approaches for fecal diversion done in patients with adenocarcinoma of the rectum as a pretreatment procedure. The primary end point of our study was time to initiation of neoadjuvant chemo radiation. It was a retrospective study that included all patients diagnosed to have carcinoma rectum and underwent a pretreatment fecal diversion between 2012 and 2014. A total of 55 patients underwent pretreatment diversion colostomy of which 33 were performed via the laparoscopic approach while 22 had open diversion. The time for initiation of neoadjuvant therapy was shorter in the laparoscopic group compared to the open approach (16 days vs. 20.5 days, P = 0.31). The study concluded that pretreatment diversion colostomy using the laparoscopic approach was a safe option in low- and middle-income countries as it was associated with faster recovery and early initiation of neoadjuvant therapy in patients with partially obstructed locally advanced carcinoma rectum.

Stent as bridge to surgery decreases postoperative complications without worsening oncological outcomes: retrospective unicentric cohort study and stent placement protocol

BACKGROUND

Even if the use of stent as bridge to surgery (BTS) for obstructive colon cancer was described long ago, there is still much controversy on their use. Patient recovery before surgery and colonic desobstruction are just some of the reasons to defend this management that can be found in several available articles.

METHODS

This is a single-center, retrospective cohort study, including patients with obstructive colon cancer treated between 2010 and 2020. The primary aim of this study is to compare medium-term oncological outcomes (overall survival, disease-free survival) between stent as BTS and ES groups. The secondary aims are to compare perioperative results (in terms of approach, morbidity and mortality, and rate of anastomosis/stomas) between both groups and, within the BTS group, analyze whether there are any factors that may influence oncological outcomes.

RESULTS

A total of 251 patients were included. Patients belonging to the BTS cohort presented a higher rate of laparoscopic approach, required less intensive care management, less reintervention, and less permanent stoma rate, when comparing with patients who underwent urgent surgery (US). There were not significant differences in terms of disease-free survival and overall survival between the two groups. Lymphovascular invasion negatively affected oncological results but was not related with stent placement.

CONCLUSION

The stent as a bridge to surgery is a good alternative to urgent surgery, which leads to a decrease in postoperative morbidity and mortality without significantly worsening oncological outcomes.

Outcomes of colon self–expandable metal stents for malignant vs benign indications at a tertiary care center and review of literature

BACKGROUND

Endoscopic placement of a self-expandable metal stent (SEMS) is a minimally invasive treatment for use in malignant and benign colonic obstruction. However, their widespread use is still limited with a nationwide analysis showing only 5.4% of patients with colon obstruction undergoing stent placement. This underutilization could be due to perceived increase risk of complications with stent placement.

AIM

To review long- and short-term clinical success of SEMS use for colonic obstruction at our center.

METHODS

We retrospectively reviewed all the patients who underwent colonic SEMS placement over a eighteen year period (August 2004 through August 2022) at our academic center. Demographics including age, gender, indication (malignant and benign), technical success, clinical success, complications (perforation, stent migration), mortality, and outcomes were recorded.

RESULTS

Sixty three patients underwent colon SEMS over an 18-year period. Fifty-five cases were for malignant indications, 8 were for benign conditions. The benign strictures included diverticular disease stricturing (n = 4), fistula closure (n = 2), extrinsic fibroid compression (n = 1), and ischemic stricture (n = 1). Forty-three of the malignant cases were due to intrinsic obstruction from primary or recurrent colon cancer; 12 were from extrinsic compression. Fifty-four strictures occurred on the left side, 3 occurred on the right and the rest in transverse colon. The total malignant case (n = 55) procedural success rate was 95% vs 100% for benign cases (P = 1.0, NS). Overall complication rate was significantly higher for benign group: Four complications were observed in the malignant group (stent migration, restenosis) vs 2 of 8 (25%) for benign obstruction (1-perforation, 1-stent migration) (P = 0.02). When stratifying complications of perforation and stent migration there was no significant difference between the two groups (P = 0.14, NS).

CONCLUSION

Colon SEMS remains a worthwhile option for colonic obstruction related to malignancy and has a high procedural and clinical success rate. Benign indications for SEMS placement appear to have similar success to malignant. While there appears to be a higher overall complication rate in benign cases, our study is limited by sample size. When evaluating for perforation alone there does not appear to be any significant difference between the two groups. SEMS placement may be a practical option for indications other that malignant obstruction. Interventional endoscopists should be aware and discuss the risk for complications in setting of benign conditions. Indications in these cases should be discussed in a multi-disciplinary fashion with colorectal surgery.

Stenting as a bridge to surgery in obstructing colon cancer: Long-term recurrence pattern and competing risk of mortality

BACKGROUND

Stenting as a bridge to curative surgery (SBTS) for obstructing colon cancer (OCC) has been associated with possibly worse oncological outcomes.

AIM

To evaluate the recurrence patterns, survival outcomes, and colorectal cancer (CRC)-specific death in patients undergoing SBTS for OCC.

METHODS

Data from 62 patients undergoing SBTS at a single tertiary centre over ten years between 2007 and 2016 were retrospectively examined. Primary outcomes were recurrence patterns, overall survival (OS), cancer-specific survival (CSS), and CRC-specific death. OS and CSS were estimated using the Kaplan-Meier curves. Competing risk analysis with cumulative incidence function (CIF) was used to estimate CRC-specific mortality with other cause-specific death as a competing event. Fine-Gray regressions were performed to determine prognostic factors of CRC-specific death. Univariate and multivariate subdistribution hazard ratios and their corresponding Wald test P values were calculated.

RESULTS

28 patients (45.2%) developed metastases after a median period of 16 mo. Among the 18 patients with single-site metastases: Four had lung-only metastases (14.3%), four had liver-only metastases (14.3%), and 10 had peritoneum-only metastases (35.7%), while 10 patients had two or more sites of metastatic disease (35.7%). The peritoneum was the most prevalent (60.7%) site of metastatic involvement (17/28). The median follow-up duration was 46 mo. 26 (41.9%) of the 62 patients died, of which 16 (61.5%) were CRC-specific deaths and 10 (38.5%) were deaths owing to other causes. The 1-, 3-, and 5-year OS probabilities were 88%, 74%, and 59%; 1-, 3-, and 5-year CSS probabilities were 97%, 83%, and 67%. The highest CIF for CRC-specific death at 60 mo was liver-only recurrence (0.69). Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictive of CRC-specific death.

CONCLUSION

The peritoneum was the most common metastatic site among patients undergoing SBTS. Liver-only recurrence, peritoneum-only recurrence, and two or more recurrence sites were predictors of CRC-specific death.

A retrospective evaluation of short-term results from colonic stenting as a bridge to elective surgery versus emergency surgery for malignant colonic obstruction

The efficacy and safety of self-expanding metallic stent (SEMS) placement as a bridge to elective surgery versus emergency surgery to treat malignant colonic obstruction is debated. This study aimed to evaluate the outcomes of patients with malignant colonic obstruction treated using different procedure. Subjects admitted to the authors' department with colonic obstruction (n = 87) were studied. They underwent colonic stenting as a bridge to elective surgery (SEMS group: n = 14) or emergency surgery (ES group: n = 22).Their demographic characteristics, stoma rate, laparoscopy rate and postoperative complications were analyzed, and the potential risk factors of postoperative complications and the optimal time interval from SEMS implantation to elective surgery were explored. The stoma rate was 15.4% in the SEMS group versus 60.0% in the ES group (P = 0.015), and the postoperative complication rate was 7.7% in the SEMS group versus 40.0% in the ES group (P = 0.042). The proportion of patients undergoing laparoscopy in SEMS group was significantly higher than that in ES group (69.2% vs. 15.0%; P = 0.003).The effect of ASA grade on postoperative complications was statistically significant (OR = 24.565; P = 0.008). The Receiving operating characteristic (ROC) curve could not determine the optimal time interval between SEMS implantation and elective surgery (AUC = 0.466). SEMS implantation has the advantages of lower temporary stoma rate, less postoperative complications and higher laparoscopy rate compared with ES in the treatment of left malignant intestinal obstruction. ASA grade is a risk factor for postoperative complications. However, larger sample size prospective randomized controlled trials (RCT) are still needed to confirm long-term oncological outcomes.

Postoperative infectious complications have a negative oncological impact in patients after stent placement with malignant large bowel obstruction

PURPOSE

In this study, we aimed to investigate the oncological impact of postoperative infection in patients with malignant large bowel obstruction managed by self-expandable metallic stent placement as a bridge to surgery.

METHODS

The cohort of this multicenter retrospective study comprised 129 patients with pathological stage II/III malignant large bowel obstruction who had undergone bridge to surgery. Patients were allocated to no-postoperative infection (n = 116) and postoperative infection groups (n = 13).

RESULTS

The postoperative infection group had a significantly greater proportion of men, fewer harvested lymph nodes, and longer postoperative hospital stays than did the no-postoperative infection group. Self-expandable metallic stent-related variables, including clinical failure, were not associated with postoperative infection. Male sex and low body mass index were identified as risk factors for postoperative infection by multivariate logistic regression. Three-year relapse-free survival rates were 75.5% and 30.8% in the no-postoperative infection and postoperative infection groups, respectively; this difference is statistically significant. Male sex, postoperative infection, and T4 were identified as independent prognostic factors by multivariate Cox proportional hazard analysis. The postoperative infection group had a significantly higher total recurrence rate and shorter interval to recurrence than did the no-postoperative infection group.

CONCLUSION

To the best of our knowledge, this is the first study to show that postoperative infection in bridge to surgery patients has a negative oncological impact. This finding indicates that further improvement in perioperative management of bridge to surgery patients is required to minimize postoperative infection and that patient-risk stratification and additional therapy would contribute to improving oncological outcomes.

Clinical Significance of Surgical Resection Timing from Endoscopic Stenting for Left-Sided Large-Bowel Obstruction in Colorectal Cancer

BACKGROUND

The optimal interval between self-expanding metallic stent (SEMS) insertion and surgery remains controversial in malignant left-sided large-bowel obstruction (MLLO), especially with respect to oncologic aspects.

AIMS

The aim of this study is to examine whether the time interval to surgery is related to oncologic outcomes.

METHODS

Prospectively collected database of MLLO between January 2005 and December 2017 were reviewed. They were divided according to established cut-off value of 14 days for the time interval to surgery. The two groups (early and late groups) were compared with respect to disease-free survival (DFS) and overall survival (OS). Additional subgroup analysis was performed using the established cut-off values for patients with stage II and III tumors.

RESULTS

A total of 149 patients underwent surgery after SEMS insertion. There were no significant differences between the early and late groups in the 5-year DFS (78.0% vs 72.4%; P = 0.513) and the OS (74.2% vs 75.7%; P = 0.864) rates in all MLLO. Subgroup analysis showed that there were significant differences between the two groups for DFS and OS in stage II MLLO. The multivariate Cox regression analysis in stage II MLLO demonstrated that the time to surgery was a prognostic factor for DFS (HR, 2.051; 95% CI, 1.528-42.136; P = 0.014) and for OS (HR, 4.947; 95% CI, 1.520-16.107; P = 0.008).

CONCLUSIONS

The time to surgery was demonstrated not to be a significant prognostic factor in all MLLO. However, it was a prognostic factor for patients with stage II MLLO.

Management of obstructive colon cancer: Current status, obstacles, and future directions

Approximately 10%–18% of patients with colon cancer present with obstruction at the initial diagnosis. Despite active screening efforts, the incidence of obstructive colon cancer remains stable. Traditionally, emergency surgery has been indicated to treat patients with obstructive colon cancer. However, compared to patients undergoing elective surgery, the morbidity and mortality rates of patients requiring emergency surgery for obstructive colon cancer are high. With the advancement of colonoscopic techniques and equipment, a self-expandable metal stent (SEMS) was introduced to relieve obstructive symptoms, allowing the patient’s general condition to be restored and for them undergo elective surgery. As the use of SEMS placement is growing, controversies about its application in potentially curable diseases have been raised. In this review, the short- and long-term outcomes of different treatment strategies, particularly emergency surgery vs SEMS placement followed by elective surgery in resectable, locally advanced obstructive colon cancer, are described based on the location of the obstructive cancer lesion. Controversies regarding each treatment strategy are discussed. To overcome current obstacles, a potential diagnostic method using circulating tumor DNA and further research directions incorporating neoadjuvant chemotherapy are introduced.

Colon stenting in benign diverticular stricture - a case report and review of literature

Background: Colonic stricture is a feared complication with varied etiology ranging from malignant obstruction to benign diseases. One such condition is recurrent diverticulitis-related strictures. Objectives & Methods: We report a case of a 48-year-old male patient with stricture of the sigmoid colon. The patient refused Sigmoid colon resection. He underwent stent placement and Two weeks later presented with constipation and abdominal discomfort. On Computed Tomography (CT) we discovered stent migration and consequent large bowel obstruction. Patient agreed on undergoing sigmoidectomy with a colostomy. Conclusion: Indication of SEMS for benign lesions remains unclear. Based on the current data, in benign colorectal obstructive lesions, SEMS is a viable option as a bridge to surgery when no other alternative option is available. However, the ASCRS 2020 guidelines did not point to SEMS as an option given the high rate of complications. Our patient was treated with a stent because he refused the resection surgery and found relief for a certain period before developing stent migration. Hence, the patients should be educated about the short and long-term potential effects of stenting before performing the procedure in benign strictures.

Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis

BACKGROUND

With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients.

METHODS

We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates.

RESULTS

We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I² = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I² = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I² = 79.3%, P < 0.001).

CONCLUSION

The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Cost-effectiveness of self-expandable metallic stents as bridge to surgery for obstructive colorectal cancer

AIM

Self-expandable metallic stent (SEMS) placement is an emergent decompression approach for patients with obstructive colorectal cancer, alongside drainage tube (DT) and emergency surgery (ES). Few reports have compared the health care cost of each treatment. We aimed to compare the efficacy of SEMS as a bridge to surgery (BTS), including health care costs during decompression and colorectal resection, with those of DT and ES.

METHODS

This retrospective study enrolled patients treated for acute obstructed colorectal cancer at a single institution from January 2007 to December 2019. A total of 45 patients that underwent placement of a DT, emergency colostomy, or SEMS insertion followed by elective radical colectomy or rectectomy for obstructed colorectal cancer were included, and their data were analyzed.

RESULTS

Among 45 patients with obstructive colorectal cancer, 29 (55.6%) patients underwent SEMS, 7 (15.6%) underwent DT, and 9 (20.0%) underwent ES as BTS. The time to oral intake from the decompression treatment in the SEMS group was significantly shorter than that of the DT and ES group (1 vs. 13 vs. 3 day, p < 0.001). Total hospitalization during the decompression and colorectal resection in the SEMS group was significantly shorter that in the DT and ES groups (23 vs. 34 vs. 44 day, p < 0.001). The total health care cost for the decompression and the colorectal resection of DT and SEMS treatment was significantly less inexpensive than ES treatment (180.8 vs. 206.7 vs. 250.3 × 10⁴ yen, p = 0.030).

CONCLUSIONS

SEMS insertion as a BTS might represent a cost-effective and safe approach compared to other treatments.

Comparison of self-expandable metallic stent placement followed by laparoscopic resection and elective laparoscopic surgery without stent placement for left-sided colon cancer

AIM

Self-expandable metallic stent (SEMS) placement for obstructive colon cancer is widely performed as a bridge to surgery (BTS) procedure before resection. This study aimed to investigate the surgical and oncological results of laparoscopic elective surgery with or without SEMS placement to assess the efficacy of SEMS placement as a BTS.

METHODS

We retrospectively analyzed consecutive patients with stage II, III, and IV left-sided colon cancer who underwent elective laparoscopic resection between 2013 and 2019. All patients were divided into two groups: with and without SEMS placement.

RESULTS

The SEMS group included 24 patients, whereas the non-SEMS group included 86 patients. The serum hemoglobin and albumin levels were lower (P = .049, P = .03), and the serum leukocyte and C-reactive protein levels were higher (P < .0001, P = .022) in the SEMS group. The tumor diameter and tumor circumferential rate were higher in the SEMS group (both P < .0001). No significant differences were observed in operation time, blood loss, postoperative complications, or postoperative hospital stay. After 1:1 propensity score matching, 15 patients in the SEMS group were compared with 15 patients in the non-SEMS group. The 3-year overall survival rates of the SEMS and non-SEMS groups were 87.5% and 88.9%, respectively (P = .97). The 3-year recurrence-free survival rates of the SEMS and non-SEMS groups were 58.2% and 81.7%, respectively (P = .233). No significant difference was found in the sites of recurrence.

CONCLUSION

The perioperative and long-term outcomes of SEMS placement as a BTS before laparoscopic resection could be acceptable compared with other elective laparoscopic operations without SEMS placement.

Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression

PURPOSE

After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes.

METHODS

Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated.

RESULTS

36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2 weeks compared to < 2 weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival.

CONCLUSIONS

Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

Current Status of the Self-Expandable Metal Stent as a Bridge to Surgery Versus Emergency Surgery in Colorectal Cancer: Results from an Updated Systematic Review and Meta-Analysis of the Literature

Background: The current use of endoscopic stenting as a bridge to surgery is not always accepted in standard clinical practice to treat neoplastic colonic obstructions. Objectives: The role of colonic self-expandable metal stent (SEMS) positioning as a bridge to resective surgery versus emergency surgery (ES) for malignant obstruction, using all new data and available variables, was studied and we focused on short- and long-term results. Materials and Methods: A systematic review with meta-analysis was performed. PubMed, SCOPUS and Web of Science databases were included. The search comprised only randomized controlled trials (RCTs) investigating the interventions that included SEMS positioning versus ES. The primary outcomes were the rates of overall postoperative mortality, clinical and technical success. The secondary outcomes were the short- and long-term results. Results: A total of 12 studies were eligible for further analyses. A laparoscopic colectomy was the most common operation performed in the SEMS group, whereas the traditional open approach was commonly used in the ES group. Intraoperative colonic lavage was seldomly performed during ES. There were no differences in mortality rates between the two groups (RR 1.06, 95% CI 0.55 to 2.04; I² = 0%). In the SEMS group, the rate of successful primary anastomosis was significantly higher in of SEMS (69.75%) than in the ES (55.07%) (RR 1.26, 95% 245 CI 1.01 to 1.57; I² = 86%). Conversely, the upfront Hartmann procedure was performed more frequently in the ES (39.1%) as compared to the SEMS group (23.4%) (RR 0.61, 95% CI 0.45 to 0.85; I² = 23%). The overall postoperative complications rate was significantly lower in the SEMS group (32.74%) than in the ES group (48.25%) (RR 0.61, 95% CI 0.41 to 0.91; I² = 65%). Conclusions: In the presence of malignant colorectal obstruction, SEMS is safe and associated with the same mortality and significantly lower morbidity than the ES group. The rate of successful primary anastomosis was significantly higher than the ES group. Nevertheless, recurrence and survival outcomes are not significantly different between the two groups. The analysis of short- and long-term results can suggest the use of SEMS as a bridge to resective surgery when it is performed by an endoscopist with adequate expertise in both colonoscopy and fluoroscopic techniques and who performed commonly colonic stenting.

Adenocarcinoma de colon sigmoide metastásico en paciente joven, presentación atípica: reporte de caso

El adenocarcinoma colorrectal es la tercera causa de muerte por cáncer en mujeres y la cuarta en hombres a nivel mundial. Se diagnostica en su mayoría en pacientes mayores a los 50 años, siendo la edad media al momento del diagnóstico los 72 años. A pesar eso, se estima que en los próximos años aumentará la incidencia en personas jóvenes y de mediana edad. Debido a esta proyección y considerando que la ausencia de signos y síntomas específicos no permite un diagnóstico oportuno, se hacen necesarias la sensibilización clínica y un alto índice de sospecha en las presentaciones atípicas. Se presenta el caso de una paciente joven que consulta por un cuadro de un mes de síntomas respiratorios quien, después de tratamiento antibiótico, antiviral e inmunomodulador sistémico, presenta sepsis de origen abdominal por peritonitis de cuatro cuadrantes secundaria a perforación de colon sigmoide debida a adenocarcinoma bien diferenciado, metastásico a pulmón, que la llevó a la muerte.

Colonic Stents as a Bridge to Surgery Compared with Immediate Resection in Patients with Malignant Large Bowel Obstruction in a NY State Database

BACKGROUND

There is controversy surrounding the efficacy and safety of colonic stents as a bridge to surgery compared with immediate resection in patients presenting with an acute malignant large bowel obstruction.

METHODS

Retrospective longitudinal cohort study using the NYS SPARCS Database. Patients with acute malignant large bowel obstruction who either had stent followed by elective surgery within 3 weeks (bridge to surgery) or underwent immediate resection between October 2009 and June 2016 in the state of New York were included. The primary outcome was rate of stoma creation at index resection. Secondary outcomes were 90-day readmission, reoperation, procedural complications, and discharge disposition.

RESULTS

A total of 3059 patients were included, n = 2917 (95.4%) underwent an immediate resection and n = 142 (4.6%) underwent bridge to surgery. We analyzed 139 patients in propensity score-matched groups. Patients in the bridge to surgery group were less likely than those in the immediate resection group to get a stoma at the time of surgery (OR 0.33, 95% CI 0.18-0.60). They were also less likely to be discharged to a rehabilitation facility or require a home health aide upon discharge (OR 0.36, 95% CI 0.22-0.61). There were no differences in rates of 90-day readmission, reoperation, or procedural complications between groups.

DISCUSSION

Colonic stenting as a bridge to surgery leads to less stoma creation, a significant quality of life advantage, compared with immediate resection. Patients should be counseled regarding these potential benefits when the technology is available.

Short- and long-term outcomes of self-expanding metallic stent placement vs. emergency surgery for malignant colorectal obstruction

The European Society of Gastrointestinal Endoscopy does not recommend self-expanding metal stent (SEMS) placement as a bridge to surgery (BTS) for malignant colorectal obstruction (MCRO). However, no universally accepted consensus has been determined. The present study aimed to evaluate the short- and long-term outcomes of SEMS placement vs. emergency surgery (ES) for MCRO. Surgical resection of colorectal cancer was performed in 3,840 patients between April 2001 and June 2016. Of these, 93 patients had MCRO requiring emergency decompression. Only patients in whom the colorectal lesion was ultimately resected were included; thus, the present study included 62 patients treated with MCRO via SEMS placement as a BTS (n=25) or via ES (n=37). The rates of laparoscopic surgery, primary anastomosis, stoma formation, lymph node dissection, adverse events, 30-day mortality and disease-free survival were evaluated. The clinical success rate of SEMS placement was 92.0% (23/25). Compared with the ES group, the SEMS group had higher rates of laparoscopic surgery (68.0 vs. 2.7%; P<0.001) and primary anastomosis (88.0 vs. 51.4%; P=0.003), a greater number of dissected lymph nodes (30 vs. 18; P=0.001), and lower incidences of stoma formation (24.0 vs. 67.6%; P=0.002) and overall adverse events (24.0 vs. 62.2%; P=0.004). The 30-day mortality and disease-free survival of the SEMS group were not significantly different to that of the ES group (0 vs. 2.7%; P=1.000; log-rank test; P=0.10). In conclusion, as long as adverse events such as perforation are minimized, SEMS placement as a BTS could be a first treatment option for MCRO. The present study is registered in the University Hospital Medical Network Clinical Trials Registry (UMIN R000034868).

When simple hernia is not that simple: Treatment of concomitant pathology in acute care surgery, a case report

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Highlighting the possibility of concurrent double pathology in acute care surgery.

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Conflicting clinical features can delay the diagnosis and alter the management.

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High index od suspicious is paramount in the interpretation of patient findings.

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In comorbid patients, we can expand the indication of radiology in small ventral hernia.

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One-stage colonic resection is still feasible in acute colonic obstruction even in.

Introduction

Obstructed colon cancer is not an uncommon surgical emergency. Many other surgical diseases may overlap their presenting symptoms. This paper aims to report a colon cancer case with delayed diagnosis due to a long-standing para-umbilical hernia (PUH).

Case report

60-year-old female patient presented to our emergency department (ED) with an obstructed PUH. The patient underwent watchful conservative management many times before due to associated comorbidities. This history of recurrent intestinal obstruction and incomplete regain of regular bowel habits after every hospital admission raises the possibility for concealed pathology. Further investigations, including computed tomography (CT), revealed a suspicion of an obstructed malignant mass at the colon's splenic flexure accompanied with complete bowel obstruction. The patient and their family consulted for exploratory laparotomy and the possibility of stoma formation. The intra-operative finding was constant with a small ventral defect, and a dilated bowel loops up to a left colon transition zone. We achieved left hemicolectomy with a primary anastomosis after intra-operative bowel lavage. The postoperative period was uneventfully, and the patient was discharged home after seven days of admission. Follow up in the outpatient surgical clinic for three months revealed no recordable complications. The patient had transferred to the oncology center for the completion of adjuvant therapy.

Discussion

This case had a small PUH with recurrent obstruction. The delay in its management was due to the patient's comorbidities. However, the incomplete resolution of patient symptoms during watchful oversight increases the likelihood of another hidden pathology that required further investigation. We expanded CT indication in such patients to find the exact cause of patient symptoms, especially chronic constipation and incomplete recovery after every admission. While concurrent pathology is the norm in elective surgery and can be dealt with safely, in non-elective surgery, a thorough search about the patient's exact complaints is mandatory to decrease morbidity and mortality rates.

Conclusion

In the same patient, both colon cancer and abdominal wall hernias can produce conflicting symptoms and delay diagnosis. However, with a high index of suspicion and correlation of patient symptoms, can be safely managed without morbidity.

Long-term outcomes of colonic stent as a "bridge to surgery"for left-sided malignant large-bowel obstruction

BACKGROUND

The role of self-expandable metallic stents (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction is still debated. Here we assess the morbidity, mortality and long-term oncological outcomes as a bridge to surgery for patients with left-sided malignant colonic obstruction.

METHOD

Prospective observational study with retrospective analysis of patients with left-sided malignant colonic obstruction undergoing stenting. April 2006-April 2018. We assessed all patients with intent-to treat and per protocol analyses and long-term follow-up variables.

RESULTS

Colonic stent was performed in 117 patients. Technical and clinical success of SEMS placement: 94.4% (111/117), only 4.3% perforation. Elective surgery resection following the strategy of SEMS was performed in 83.8% (98/117). A laparoscopic approach was: 25.6% (30/117); 76.9% in the last two years. Primary anastomosis rate: 92.8% (91/98), without protective stoma in any patients. Anastomotic leakage rate: 8.2% (8/97). Median follow-up: 44.5 months (range 0-109). The intent-to-treat analysis showed overall and disease-free survival rates of 63.3% (74/117) and 58.1% (68/117), and local and distant recurrence rates: 9.4% (11/117) and 58.1% (68/117). In the per protocol analysis, overall and disease-free survival rates: 63.2% (62/98) and 60.2% (58/98), and local and distant recurrence rates: 10.2% (10/98) and 36.7% (36/98). Disease progression was predominantly observed during the first 5 years' follow-up as disease recurrence; after five years' follow-up, 60% of the patients were disease-free.

CONCLUSIONS

According to the results of the study SEMS as a bridge to surgery achieves perioperative results comparable to non-occlusive colonic cancer surgery and does not adversely affect long-term oncological outcomes. Further investigations are needed.

Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?

For the 8-29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation. More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used. Despite these attractive outcomes, the superiority of the BTS approach is not clearly established. Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis. For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches. This lack of consensus has spawned differing and sometimes discordant guidelines worldwide. In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic. We hope that these data will finally converge on a single set of recommendations supporting a management strategy with well-demonstrated superiority.

Management Considerations for the Surgical Treatment of Colorectal Cancer During the Global Covid-19 Pandemic

OBJECTIVE

The COVID-19 pandemic requires to conscientiously weigh "timely surgical intervention" for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers.

SUMMARY BACKGROUND DATA

Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery.

METHODS

Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation, and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize nonsurgical modalities to bridge the waiting period.

RESULTS

Colorectal cancer surgeries-prioritized as emergency, urgent with imminent emergency or oncologically urgent, or elective-were matched against the phases of the pandemic. Surgery in COVID-19-positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(-12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients.

CONCLUSIONS

The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage, and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.

Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis

PURPOSE

The placement of self-expandable metallic stents as a bridge to surgery in malignant colon obstruction is concerning due to the long-term oncological results reported in recent published studies. The aim of this study was to evaluate the oncological consequences of stent-related perforations in patients with malignant colon obstruction and potentially curable disease.

METHODS

MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed five meta-analyses to estimate the pooled effect sizes by using a random-effect model. The outcomes were global, locoregional and systemic recurrence rate and 3 and 5 year-survival rate depending on the presence or absence of stent-related perforation.

RESULTS

Thirteen studies (950 patients) were included. The overall rate of stent-related perforation was 8.9%. The global recurrence rate was significantly higher in stent-related perforation group (41.2 vs. 30.8%; OR 1.70; 95%CI: 1.02-2.84; p = 0.04). Locoregional recurrence rate was higher in the perforated group than in the non-perforated group (26.6 vs. 12.5%), with statistically significant differences (OR 2.41; 95% CI:1.33-4.34; p = 0.004). No significant differences were found in systemic recurrence rate (13.6 vs. 20.5%; OR 0.77; 95%CI: 0.35-1.7; p = 0.51); 3-year overall survival rate (65.4 vs. 74.8%; OR 0.63; 95% CI:0.29-1.39; p = 0.25) and 5-year overall survival rate (48.3 vs. 58.6%; OR 0.67; 95%CI: 0.27-1.65; p = 0.38).

CONCLUSION

Stent-related perforation is associated with an increased risk of global and locoregional recurrence. The successful placement of the stent as a bridge to surgery in the curative purpose of patients with obstructed colon cancer does not exclude the presence of underlying perforation, with the consequent danger of disease spread. PROSPERO registration number: CRD42020152817.

Comparison of colonic stents, stomas and resection for obstructive left colon cancer: a meta-analysis

BACKGROUND

Emergency surgery (ES) is the standard-of-care for left-sided obstructing colon cancer, with self-expanding metallic stents (SEMSs) and diverting colostomies (DCs) being alternative approaches. The aim of this study was to review the short- and long-term outcomes of SEMS versus ES or DC.

METHODS

Embase and Medline were searched for articles comparing SEMS versus ES or DC. Primary outcomes were survival and recurrence rates. Secondary outcomes were peri- and postoperative outcomes. SEMS-specific outcomes include success and complication rates. Pooled odds ratio and 95% confidence interval were estimated with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Thirty-three studies were included, involving 15,224 patients in 8 randomized controlled trials and 25 observational studies. There were high technical and clinical success rates for SEMS, with low rates of complications. Our meta-analysis revealed increased odds of laparoscopic surgery and anastomosis, and decreased stoma creation with SEMS compared to ES. SEMS led to fewer complications, including anastomotic leak, wound infection, ileus, myocardial infarction, and improved 90-day in-hospital mortality. There were no significant differences in 3- and 5-year overall, cancer-specific and disease-free survival. SEMS, compared to DC, led to decreased rates of stoma creation, higher rates of ileus and reoperation, and led to longer hospital stay.

CONCLUSIONS

SEMS leads to better short-term outcomes but confers no survival advantage over ES. It is unclear whether SEMS has better short-term outcomes compared to DC. There is a lack of randomized trials with long-term outcomes for SEMS versus DC, hence results should be interpreted with caution.

Fluoroscopic Stenting as a Bridge to Surgery versus Emergency Management for Malignant Obstruction of the Colon

Aim

To investigate the feasibility of a SEMS (self-expandable metallic stent) as a bridge to surgery for malignant colonic obstruction.

Methods

We retrospectively reviewed 83 patients that were in accordance with inclusion criteria; of these, 33 patients that underwent fluoroscopy-guided SEMS placement followed by elective curative resection were classified as a SEMS group and 50 patients, who received emergency surgery (ES), were classified as an ES group. The clinicopathological characteristics, surgery-related parameters, complications, and three-year survival rate were compared between the two groups.

Results

No significant differences between the two groups were observed in any of the clinicopathologic characteristics except for higher preoperative absolute neutrophil count in the ES group (P < 0.001). Compared to the ES group, the SEMS group has significantly more cases, which featured a laparoscopic approach (72.7% vs. 14.0%, P < 0.001), lower overall stoma rate (0% vs. 34.0%, P < 0.001), and lower overall postoperative morbidity (27.3% vs. 56.0%, P=0.010). The oncological outcomes did not differ significantly between the two groups in terms of three-year overall survival (P=0.125). The technical and clinical success rates of stent placement were 91.7% and 100%, respectively.

Conclusion

Patients treated with the stent-surgery approach had significant short-term superiorities and similar long-term outcomes, compared to patients who had emergency surgery alone. The SEMS is, therefore, safe and feasible as a bridge to surgery for malignant colonic obstruction.

Obstructive left side colon cancer: time for a tailored operative approach?

BACKGROUND

Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases.

METHODS

Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety.

RESULTS

One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH.

CONCLUSIONS

The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.

Stent as a bridge to surgery or immediate colectomy for malignant right colonic obstruction: propensity-scored, national database study

Background

The aim of this study was to compare perioperative outcomes of urgent colectomy and placement of a self-expanding metallic stent followed by colectomy for patients with malignant right colonic obstruction. Right-sided malignant obstruction is less common than left-sided. Stenting for malignant left colonic obstruction has been reported to reduce postoperative complications. However, the impact of stenting for malignant right colonic obstruction remains undefined.

Methods

The study included patients with right-sided malignant obstruction or stenosis undergoing colectomy between April 2012 and March 2017 identified from a nationwide database. Propensity score matching analysis was used to compare mortality and morbidity rates, proportion receiving a stoma and postoperative stay between urgent colectomy and stent groups.

Results

From 9572 patients, 1500 pairs were generated by propensity score matching. There was no significant difference in in-hospital mortality between the urgent colostomy and stent groups (1·6 versus 0·9 per cent respectively; P = 0·069). Complications were more common after urgent colectomy than stenting (22·1 versus 19·1 per cent; P = 0·042). Surgical-site infection was more likely with urgent colectomy (7·1 versus 4·4 per cent; P = 0·001). There was no significant difference between the two groups in anastomotic leakage (3·8 versus 2·6 per cent; P = 0·062). The proportion of patients needing a stoma was higher with urgent colectomy than primary treatment with stents (5·1 versus 1·7 per cent; P &lt; 0·001). Postoperative stay was longer after urgent colectomy (15 versus 13 days; P &lt; 0·001).

Conclusion

Stenting followed by colectomy in patients with malignant right colonic obstruction may provide more favourable perioperative outcomes than urgent colectomy.

Technical and Clinical Outcomes After Colorectal Stenting in Malignant Large Bowel Obstruction: A Single-Center Experience

Purpose

Malignant large bowel obstruction is a surgical emergency that requires urgent decompression. Stents are increasingly being used, though reported outcomes are variable. We describe our multidisciplinary experience in using stents to manage malignant large bowel obstruction.

Methods

All patients undergoing colorectal stent insertion for acute large bowel obstruction in a teaching hospital were included. Outcomes, complications, and length of stay (LOS) were recorded.

Results

Over a 7-year period, 73 procedures were performed on 67 patients (37 male, mean age of 76 years). Interventional radiology was involved in all cases. Endoscopic guidance was required in 24 cases (32.9%). In 18 patients (26.9%), treatment intent was to bridge to elective surgery; 16 had successful stent placement; all had subsequent curative resection (laparoscopic resection, 8 of 18; primary anastomosis, 14 of 18). Overall LOS, including both index admission and elective admission, was 16.4 days. Treatment intent was palliative in 49 patients (73.1%). In this group, stents were successfully placed in 41 of 49 (83.7%). Complication rate within 30 days was 20%, including perforation (2 patients), per rectal bleeding (2), stent migration (1), and stent passage (5). Nineteen patients (38.8%) required subsequent stoma formation (6, during same admission; 13, during subsequent admission). Overall LOS was 16.9 days.

Conclusion

In our experience colorectal stents can be used effectively to manage malignant large bowel obstruction, with only selective endoscopic input. As a bridge to surgery, most patients can avoid emergency surgery and have a primary anastomosis. In the palliative setting, the complication rate is acceptable and two-thirds avoid a permanent stoma.

Endoscopic Management of Malignant Colonic Obstruction

Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.

Endoscopic stenting in colorectal cancer

Acute malignant large bowel obstruction presents as one of the few emergencies of colorectal cancer (CRC). Management of this condition can either be by (I) upfront surgery or (II) the use of self-expanding metallic stent (SEMS) as a bridge to elective surgery. For patients with metastasis, the use of SEMS is reported to enable earlier commencement of chemotherapy. Although the use of SEMS in patients with acute malignant large bowel obstruction looks promising, it is plagued by its own set of complications and divided opinion over its long-term outcomes. Conflicting data are present, and definitive indication requires further evaluation and debate. This article will describe the typical presentation of patients with acute malignant large bowel obstruction. An introduction to the SEMS insertion procedural steps will be undertaken. Following which the article aims to review the safety profile of SEMS and the short- and long-term outcomes of SEMS in both the curative and palliative setting.

The long-term recurrence rate and survival of obstructive left-sided colon cancer patients: a stent as a bridge to surgery

BACKGROUND

a colonic stent as a bridge to elective surgery for left-sided malignant colonic obstruction is an alternative to the classical treatment. The aim of our study was to evaluate the recurrence rate as well as the morbidity and mortality of this treatment.

PATIENTS AND METHODS

patients admitted to the Emergency Department with left-sided malignant colonic obstruction between June 2006 and January 2014 were analyzed in a retrospective observational study. Patients who underwent self-expanding metallic stent placement via endoscopy as a bridge to surgery were included. The observation period was performed until May 2017.

RESULTS

fifty-three patients were treated with a colonic stent as a bridge to surgery; nine patients died during the postoperative period. The deceased patients were more frequently male (100% in the deceased vs 62% in the non-deceased, p = 0.02), with a more advanced age (81.4 ± 5.1 vs 71.6 ± 10.8, p < 0.001), lower hemoglobin levels on admission (12.9 vs 13.6 p < 0.001), a greater number of leukocytes (12,918 vs 9,437, p < 0.001) and greater coagulopathy (INR 1.6 vs 1, p < 0.001). Eight patients had a distant relapse with a median disease-free survival of 19.1 months. The variables were compared according to the appearance of distant disease and the mean age was lower in patients with a recurrence (65.9 ± 11.3 vs 74.9 ± 9.9, p < 0.001).

CONCLUSIONS

the results of the use of a stent as a bridge to curative surgery in patients with obstructive left colon cancer in our hospital is comparable to previous studies.

Outcomes following colonic stenting for malignant left-sided bowel obstruction: a systematic review of randomised controlled trials

PURPOSE

Malignant bowel obstruction is a common presentation and is associated with high morbidity and mortality. Emergency resection is the traditional treatment modality. In recent years, colonic stenting as a bridge to surgery has become more prevalent. However, there is considerable debate surrounding its use. The aim of this review was to examine the technical and clinical success of self-expanding metal stent (SEMS) as a bridge to surgery for obstructing colorectal tumours.

METHODS

We systematically reviewed randomised controlled trials using PubMed, Cochrane and SCOPUS databases. Included studies must have compared outcomes in SEMS as a bridge to surgery with those proceeding straight to emergency resection.

RESULTS

A total of 1245 studies were identified. After removal of duplicates and non-relevant studies, we identified seven articles which met the predefined criteria. This review observed that 81% of SEMS were technically successful, with 76% of patients having restoration of gastrointestinal function. Iatrogenic perforation rate was 5%. One-fifth of patients required emergency surgery following stent placement, and permanent stoma rate was 8.7%.

CONCLUSION

This study observed that SEMS as a bridge to surgery is associated with good technical and clinical success, with low rates of perforation and permanent stoma. SEMS should be part of the treatment armamentarium for obstructing colorectal neoplasms, but careful patient selection and institutional expertise are important factors for success.

Management of Malignant Large-Bowel Obstruction

An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.

Better recurrence-free survival after stent bridge to surgery compared to emergency surgery for obstructive left-sided colonic cancer in patients with stage III status of the American Joint Committee on Cancer (AJCC): a bicentric retrospective study

PURPOSE

Stenting as a bridge to surgery (SBTS) can transform an emergency surgery (ES) into an elective surgery in patients with symptomatic left-sided malignant colonic obstruction. Concerns have been raised regarding short-term morbidity and long-term oncologic outcomes, with contrasting results reported in the literature. Our main aim is to evaluate not only long-term oncologic outcomes but also short-term postoperative outcomes of stented patients who underwent elective surgery compared to those who had ES.

METHODS

From January 2006 to May 2012, we retrospectively identified patients with confirmed left-sided colorectal cancer obstruction. This was done in two centers of reference of colorectal diseases in southern Spain with patients who were treated with curative intent either with ES or SBTS. The short- and long-term results were compared between both groups.

RESULTS

There were 71 patients in the stenting group and 66 in the emergency surgery group, with similar demographic data. Initial stoma creation rates were lower in the SBTS group (16.9% vs. 54.5%, p < 0.005) and the primary anastomosis rate was higher in the same group (83.1% vs. 45.5%, p < 0.005). Five-year recurrence-free survival (RFS) rates were comparable between groups (75.3 vs. 59.8%, p = 0.220), but RFS rates at 5 years for AJCC pathologic stage III were higher in the stenting group (69.7% vs 30%, p = 0.004). Both groups were comparable regarding overall and cancer-specific survival outcomes.

CONCLUSIONS

The use of SBTS reduces ostomy rates in patients with obstructive colon malignancies. Long-term survival results are similar. Patients in the SBTS group with stage III AJCC status showed a higher 5-year recurrence-free survival rate than those in the ES group.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes

INTRODUCTION

Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection.

METHODS

A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival.

RESULTS

Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%.

CONCLUSION

Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.

Colonic Stent Use in Patients With Malignant Flexure Tumors Presenting With Obstruction

Background and Objective:

Colonic stenting in left-sided tumor is being commonly used. However, placing a stent in the flexure tumors is rare because it is technically more difficult. In this study, we aimed to retrospectively screen patients with flexure tumors admitted to our clinic who were treated using a colonic stent and discuss our findings.

Methods:

Patients admitted to the emergency department for obstructive colonic tumors between 2012 and 2017 were retrospectively evaluated, and 21 patients treated using stents were included in the study. The expandable metal stent (Wallflex®, Boston Scientific, Marlborough, MA, USA) was placed at the obstruction through the lead wire.

Results:

The mean age of the patients was 62 years, and the ratio of females to males was 3:18. Splenic flexure tumors were detected in 18 patients and hepatic flexure tumors in 3 patients. Seven of the patients were stented for palliative purposes. Fourteen of the cases underwent surgery. Three of them underwent laparoscopic surgery and eleven underwent open surgery.

Conclusions:

Preoperative stenting in colonic flexura tumors is associated with faster healing, less postoperative complications, lower rates of colostomy, and higher rates of minimally invasive surgery, and can be safely used at experienced centers.

Acute abdominal obstruction: Colon stent or emergency surgery? An evidence-based review

According to the American Cancer Society and Colorectal Cancer Statistics 2017, colorectal cancer (CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018. Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction (MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990s, self-expanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.

Fluoroscopy-guided long intestinal tube placement for the treatment of malignant bowel obstruction

The aim of the present study was to investigate the safety and efficacy of long intestinal tube placement under fluoroscopic guidance for the treatment of malignant bowel obstruction (MBO). The cases of 74 patients with MBO who underwent long intestinal tube placement under fluoroscopic guidance during the period between June 2015 and October 2017 were reviewed. The clinical characteristics were retrospectively analysed with respect to efficacy, safety and outcome. Long intestinal tube placement was successfully completed in all 74 patients. The mean time required for tube placement was 31.09±16.25 min and the mean insertion depth of the tube was 153±39 cm. In 58 cases, the symptoms of abdominal pain, abdominal bloating and vomiting were greatly improved following 1-3 days of tube decompression. The symptoms of the remaining 16 patients were not effectively relieved following decompression. No serious complications were observed in any patients. Overall, for patients with severe MBO, long intestinal tube placement under fluoroscopic guidance appears to be an effective and safe treatment, and it may improve quality of life.